PRECAUTIONS SECTION.

PRECAUTIONS. General. As with other antibacterials, use of this drug may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, discontinue antibacterial and institute appropriate therapy.Treat all infections due to Group beta-hemolytic streptococci for at least ten days.Perform incision and drainage or other surgical procedures in conjunction with antibacterial therapy, when indicated.Prescribing tetracycline in the absence of proven or strongly suspected bacterial infection or prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.. Information for Patients. Counsel patients that antibacterial drugs including tetracycline should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When tetracycline is prescribed to treat bacterial infection, tell patients that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by tetracycline or other antibacterial drugs in the future.. Laboratory Tests. In sexually transmitted infections, when coexistent syphilis is suspected, perform dark field examinations before treatment is started and the blood serology repeated monthly for at least four months.. Drug Interactions. Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, it is advisable to avoid giving tetracycline in conjunction with penicillin or other bactericidal antibacterials.Because the tetracyclines have been shown to depress plasma prothrombin activity, patients who are on anticoagulant therapy may require downward adjustment of their anticoagulant dosage.The concurrent use of tetracycline and methoxyflurane has been reported to result in fatal renal toxicity.Absorption of tetracyclines is impaired by antacids containing aluminum, calcium or magnesium and preparations containing iron, zinc, or sodium bicarbonate.Concurrent use of tetracycline may render oral contraceptives less effective.. Carcinogenesis, Mutagenesis, Impairment of Fertility. Long-term animal studies are currently being conducted to determine whether tetracycline hydrochloride has carcinogenic potential. Some related antibacterials (oxytetracycline, minocycline) have shown evidence of oncogenic activity in rats.In two in vitro mammalian cell assay systems (L 51784y mouse lymphoma and Chinese hamster lung cells), there was evidence of mutagenicity with tetracycline hydrochloride.Tetracycline hydrochloride had no effect on fertility when administered in the diet to male and female rats at daily intake of approximately 400 mg/kg/day, roughly times the highest recommended human dose based on body surface area.. Pregnancy. Teratogenic EffectsPregnancy Category D(see WARNINGS)Nonteratogenic Effects(see WARNINGS)Pregnant women with renal disease may be more prone to develop tetracycline-associated liver failure.. Labor and Delivery. The effect of tetracyclines on labor and delivery is unknown.. Nursing Mothers. Because of potential for serious adverse reaction in nursing infants from tetracyclines, decision should be made whether to discontinue the drug, taking into account the importance of the drug to the mother (see WARNINGS).. Pediatric Use. See WARNINGS and DOSAGE AND ADMINISTRATION.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Tetracyclines are readily absorbed and are bound to plasma protein in varying degrees. They are concentrated by the liver in the bile and excreted in the urine and feces at high concentrations in biologically active form.MicrobiologyTetracyclines are primarily bacteriostatic and exert their antimicrobial effect by the inhibition of protein synthesis by binding to the 30S ribosomal subunit. Tetracycline is active against broad range of gram-negative and gram-positive organisms. The drugs in the tetracycline class have closely similar antimicrobial spectra, and cross-resistance among them is common.Tetracycline has been shown to be active against most isolates of the following bacteria, both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section of the package insert.Gram-negativeBacteria Acinetobacter speciesBartonella bacilliformisBrucella species Campylobacter fetusEnterobacter aerogenesEscherichia coliFrancisella tularensisHaemophilus ducreyiHaemophilus influenzaeKlebsiella species Klebsiella granulomatisNeisseria gonorrhoeaeShigella species Vibrio choleraeYersinia pestis Gram-positive Bacteria Bacillus anthracisStreptococcus pyogenesStreptococcus pneumoniaeStaphylococcus aureusListeria monocytogenes Anaerobes Bacteroides speciesClostridium species Fusobacterium fusiformePropionibacterium acnes Other Bacteria Actinomyces speciesBorrelia recurrentisChlamydophila psittaciChlamydia trachomatisRickettsiaeTreponema pallidumTreponema pallidum subspecies pertenue Parasites Entamoeba speciesBalantidium coli Susceptibility Test Methods When available, the clinical microbiology laboratory should provide the results of in vitro susceptibility test results for antimicrobial drugs used in resident hospitals to the physician as periodic reports that describe the susceptibility profile of nosocomial and community-acquired pathogens. These reports should aid the physician in selecting the most effective antimicrobial. Dilution Techniques Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using standardized test method1,2,4 (broth and/or agar). The MIC values should be interpreted according to the criteria provided in Table 1. Diffusion Techniques Quantitative methods that require measurement of zone diameters can also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The zone size provides an estimate of the susceptibility of bacteria to antimicrobial compounds. The zone size should be determined using standard test method1,3,4. This procedure uses paper disks impregnated with 30 mcg tetracycline to test the susceptibility of bacteria to tetracycline. The disk diffusion interpretive criteria are provided in Table 1. Anaerobic Techniques For anaerobic bacteria, the susceptibility to tetracycline can be determined by standardized test method5. The MIC values obtained should be interpreted according to the criteria provided in Table 1.Table 1: Susceptibility Test Interpretive Criteria for TetracyclineBacteriaa Minimal Inhibitory Concentration (mcg/mL)ZoneDiameter(mm)Agar Dilution (mcg/mL)SIRSIRSIRAcinetobacter spp.<48>16>1512-14<11---Anaerobes------<48>16Bacillusanthracisa <1--------Brucella speciesa <1--------Enterobacteriaceae<48>16>1512-14<11---Franciscellatularensisa <4--------Haemophilus influenzae <24>8>2926-28<25---Mycoplasma pneumoniae------<2--Neisseria gonorrhoeaeb --->3831-37<30<0.250.5-1>2Staphylococcus aureus<48>16>1915-18<14---Streptococcus pneumoniae<12>4>2825-27<24---Streptococcus pyogenes<24>8>2319-22<18---Vibrio cholerae<48>16>1512-14<11---Yersinia pestis<48>16------aThe current absence of resistance isolates precludes defining any results other than Susceptible. If isolates yielding MIC results other than susceptible, they should be submitted to reference laboratory for further testing.bGonococci with 30 mcg tetracycline disk zone diameters of less than 19 mm usually indicate plasmid-mediated tetracycline resistant Neisseria gonorrhoeae isolate. Resistance in these strains should be confirmed by dilution test (MIC greater than or equal to 16 mcg/mL).A report of Susceptible (S) indicates that the antimicrobial is likely to inhibit growth of the pathogen if the antimicrobial compound reaches the concentrations usually achievable at the site of infection. report of Intermediate (I) indicates that the result should be considered equivocal, and, if the bacteria is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides buffer zone that prevents small uncontrolled technical factors from causing major discrepancies in interpretation. report of Resistant (R) indicates that the antimicrobial is not likely to inhibit growth of the pathogen if the antimicrobial compound reaches the concentrations usually achievable at the infection site; other therapy should be selected.Quality Control Standardized susceptibility test procedures require the use of laboratory controls to monitor and ensure the accuracy and precision of the supplies and reagents used in the assay, and the techniques of the individuals performing the test1,2,3,4,5,6,7. Standard tetracycline powders should provide the following range of MIC values noted in Table 2. For the diffusion technique using the 30 mcg tetracycline disk the criteria noted in Table should be achieved.Table 2: Acceptable Quality Control Ranges for Susceptibility Testing for TetracyclineQC StrainMinimalInhibitory Concentration (mcg/mL)Zone Diameter (mm)Agar Dilution (mcg/mL)Enterococcus faecalis ATCC 292128 32--Escherichia coli ATCC 259220.5 218 25-Haemophilus influenzae ATCC 492474 3214 22-Mycoplasma pneumoniae ATCC 293420.06-0.5-0.06-0.5Neisseria gonorrhoeae ATCC 49226-30 420.25 1Staphylococcus aureus ATCC 25923-24 30-Staphylococcus aureus ATCC 292130.12 1--Streptococcus pneumoniae ATCC 496190.06 0.527 31-Bacteroides fragilis ATCC 25285--0.12 0.5Bacteroides thetaiotaomicron ATCC 29741--8 32.

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. Gastrointestinal: anorexia, nausea, epigastric distress, vomiting, diarrhea, glossitis, black hairy tongue, dysphagia, enterocolitis, and inflammatory lesions (with Candida overgrowth) in the anogenital region.Esophagitis and esophageal ulceration have been reported in patients receiving particularly the capsule and also the tablet forms of tetracyclines.Most of the patients were reported to have taken medication immediately before going to bed (see DOSAGE AND ADMINISTRATION).Teeth: permanent discoloration of teeth may be caused during tooth development. Enamel hypoplasia has been reported (see WARNINGS).Skin: maculopapular and erythrematous rashes. Exfoliative dermatitis has been reported. Onycholysis and discoloration of the nails have been reported. Photosensitivity is discussed in WARNINGS.Renal Toxicity: an increase in BUN has been reported and is dose related.Liver: hepatotoxicity and liver failure have been observed in patients receiving tetracycline and in tetracycline-treated patients with renal impairment.Hypersensitivity Reactions: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura, pericarditis, exacerbation of systemic lupus erythematosus, and serum sickness-like reactions, as fever, rash, and arthralgia.Blood: hemolytic anemia, thrombocytopenia, thrombocytopenic purpura, neutropenia and eosinophilia have been reported.When given over prolonged periods, tetracyclines have been reported to produce brown-black microscopic discoloration of thyroid glands. No abnormalities of thyroid function studies are known to occur.

DOSAGE & ADMINISTRATION SECTION.

DOSAGE AND ADMINISTRATION. Adults: Usual daily dose, gram as 500 mg twice day or 250 mg four times day. Higher doses such as 500 mg four times day may be required for severe infections or for those infections which do not respond to the smaller doses.For pediatric patients above eight years of age: Usual daily dose, 10 mg/lb to 20 mg/lb (25 mg/kg to 50 mg/kg) body weight divided in four equal doses.Administration of adequate amounts of fluid with the tablet formulation of tetracycline is recommended to wash down the drug and reduce the risk of esophageal irritation and ulceration (see ADVERSE REACTIONS).Absorption of tetracycline is impaired by antacids containing aluminum, calcium or magnesium and preparations containing iron, zinc or sodium bicarbonate. Food and some dairy products also interfere with absorption.When used in streptococcal infections, therapy should be continued for 10 days.For treatment of brucellosis, 500 mg tetracycline hydrochloride tablets four times day for three weeks accompanied by streptomycin, gram intramuscularly twice daily the first week and once daily the second week.For the treatment of syphilis in patients allergic to penicillin, the following dosage of tetracycline hydrochloride tablets is recommended: early syphilis (less than one years duration), 500 mg four times day for 15 days. Syphilis of more than one years duration (except neurosyphilis), 500 mg four times day for 30 days.For treatment of gonorrhea, the recommended dose is 500 mg by mouth four times day for seven days.Uncomplicated urethral, endocervical or rectal infections in adults caused by Chlamydiatrachomatis: 500 mg, by mouth, four times day for at least seven days.In cases of moderate to severe acne which, in the judgement of the clinician, require long-term treatment, the recommended initial dosage is gram daily in divided doses. When improvement is noted, reduce dosage gradually to maintenance levels ranging from 125 mg to 500 mg daily. In some patients it may be possible to maintain adequate remission of lesions with alternate day or intermittent therapy. Tetracycline hydrochloride tablets therapy of acne should augment the other standard measures known to be of value. Duration of long-term treatment which can safely be recommended has not been established (see WARNINGS and Carcinogenesis, Mutagenesis, Impairment of Fertility).. Use in Specific Population. In patients with renal impairment (see WARNINGS): decrease total dosage by reduction of recommended individual doses and/or by extending time intervals between doses.

INDICATIONS & USAGE SECTION.

INDICATIONS AND USAGE. To reduce the development of drug-resistant bacteria and maintain the effectiveness of tetracycline hydrochloride and other antibacterial drugs, tetracycline hydrochloride tablets should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.Tetracycline hydrochloride tablets are indicated in the treatment of infections caused by susceptible strains of the designated organisms in the conditions listed below:Upper respiratory tract infections caused by Streptococcus pyogenes, Streptococcus pneumoniae and Hemophilus influenzae. Note: Tetracycline hydrochloride tablets should not be used for streptococcal disease unless the organism has been demonstrated to be susceptible.Lower respiratory tract infections caused by Streptococcus pyogenes, Streptococcus pneumoniae, Mycoplasma pneumoniae (Eaton agent, and Klebsiella sp.)Skin and soft tissue infections caused by Streptococcus pyogenes, Staphylococcus aureaus. (Tetracyclines are not the drugs of choice in the treatment of any type of staphylococcal infections.)Infections caused by rickettsia including Rocky Mountain spotted fever, typhus group infections, fever, rickettsialpox.Psittacosis caused by Chlamydophila psittaci.Infections caused by Chlamydia trachomatis such as uncomplicated urethral, endocervical or rectal infections, inclusion conjunctivitis, trachoma, and lymphogranuloma venereum.Granuloma inquinale caused by Klebsiella granulomatis.Relapsing fever caused by Borrelia sp. Bartonellosis caused by Bartonella bacilliformis.Chancroid caused by Hemophilus ducreyi.Tularemia caused by Francisella tularensis.Plaque caused by Yersinia pestis.Cholera caused by Vibrio cholerae.Brucellosis caused by Brucella species (tetracycline hydrochloride tablets may be used in conjunction with an aminoglycoside).Infections due to Campylobacter fetus.As adjunctive therapy in intestinal amebiasis caused by Entamoeba histolytica.Urinary tract infections caused by susceptible strains of Escherichia coli, Klebsiella, etc.Other infections caused by susceptible gram-negative organisms such as E. coli, Enterobacter aerogenes, Shigella sp., Acinetobacter sp., Klebsiella sp., and Bacteroides sp. In severe acne, adjunctive therapy with tetracycline hydrochloride tablets may be useful. When penicillin is contraindicated, tetracyclines are alternative drugs in the treatment of the following infections: Syphilis and yaws caused by Treponema pallidum and pertenue, respectively,Vincents infection caused by Fusobacterium fusiforme,Infections caused by Neisseria gonorrhoeae, Anthrax caused by Bacillus anthracis, Infections due to Listeria monocytogenes, Actinomycosis caused by Actinomyces species,Infections due to Clostridium species.. Upper respiratory tract infections caused by Streptococcus pyogenes, Streptococcus pneumoniae and Hemophilus influenzae. Note: Tetracycline hydrochloride tablets should not be used for streptococcal disease unless the organism has been demonstrated to be susceptible.. Lower respiratory tract infections caused by Streptococcus pyogenes, Streptococcus pneumoniae, Mycoplasma pneumoniae (Eaton agent, and Klebsiella sp.). Skin and soft tissue infections caused by Streptococcus pyogenes, Staphylococcus aureaus. (Tetracyclines are not the drugs of choice in the treatment of any type of staphylococcal infections.). Infections caused by rickettsia including Rocky Mountain spotted fever, typhus group infections, fever, rickettsialpox.. Psittacosis caused by Chlamydophila psittaci.. Infections caused by Chlamydia trachomatis such as uncomplicated urethral, endocervical or rectal infections, inclusion conjunctivitis, trachoma, and lymphogranuloma venereum.. Granuloma inquinale caused by Klebsiella granulomatis.. Relapsing fever caused by Borrelia sp. Bartonellosis caused by Bartonella bacilliformis.. Chancroid caused by Hemophilus ducreyi.. Tularemia caused by Francisella tularensis.. Plaque caused by Yersinia pestis.. Cholera caused by Vibrio cholerae.. Brucellosis caused by Brucella species (tetracycline hydrochloride tablets may be used in conjunction with an aminoglycoside).. Infections due to Campylobacter fetus.. As adjunctive therapy in intestinal amebiasis caused by Entamoeba histolytica.. Urinary tract infections caused by susceptible strains of Escherichia coli, Klebsiella, etc.. Other infections caused by susceptible gram-negative organisms such as E. coli, Enterobacter aerogenes, Shigella sp., Acinetobacter sp., Klebsiella sp., and Bacteroides sp. In severe acne, adjunctive therapy with tetracycline hydrochloride tablets may be useful. When penicillin is contraindicated, tetracyclines are alternative drugs in the treatment of the following infections: Syphilis and yaws caused by Treponema pallidum and pertenue, respectively,. Vincents infection caused by Fusobacterium fusiforme,. Infections caused by Neisseria gonorrhoeae, Anthrax caused by Bacillus anthracis, Infections due to Listeria monocytogenes, Actinomycosis caused by Actinomyces species,. Infections due to Clostridium species.

REFERENCES SECTION.

REFERENCES. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; Twenty-fifth Informational Supplement, CLSI document M100-S24. CLSI document M100-S25 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.Clinical and Laboratory Standards Institute (CLSI). Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically; Approved Standard Tenth Edition. CLSI document M07- A10 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA,Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Disk Diffusion Susceptibility Tests; Approved Standard Eleventh Edition. CLSI document M02-A12 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.Clinical and Laboratory Standards Institute (CLSI). Methods for Antimicrobial Dilution and Disk Susceptibility Testing of Infrequently Isolated or Fastidious Bacteria; Approved Guideline Second Edition. CLSI document M45-A2, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA, 2010.Clinical and Laboratory Standards Institute (CLSI). Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard Eighth Edition. CLSI document M11-A8. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2012.Clinical and Laboratory Standards Institute. Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic Actinomycetes; Approved Standard--Second Edition. CLSI document M24-A2. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2011.Clinical and Laboratory Standards Institute. Methods for Antimicrobial Susceptibility Testing for Human Mycoplasmas; Approved Guideline. CLSI document M43-A. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2011.Rx onlyDist. by:Par Pharmaceutical Chestnut Ridge, NY 10977 U.S.A.Mfg. by:Par Formulations Private Limited,9/215, Pudupakkam, Kelambakkam 603 103. Made in IndiaMfg. Lic. No.: TN00002121OS732-01-74-01Issued: 06/2017. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; Twenty-fifth Informational Supplement, CLSI document M100-S24. CLSI document M100-S25 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.. Clinical and Laboratory Standards Institute (CLSI). Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically; Approved Standard Tenth Edition. CLSI document M07- A10 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA,. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Disk Diffusion Susceptibility Tests; Approved Standard Eleventh Edition. CLSI document M02-A12 [2015], Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.. Clinical and Laboratory Standards Institute (CLSI). Methods for Antimicrobial Dilution and Disk Susceptibility Testing of Infrequently Isolated or Fastidious Bacteria; Approved Guideline Second Edition. CLSI document M45-A2, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA, 2010.. Clinical and Laboratory Standards Institute (CLSI). Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard Eighth Edition. CLSI document M11-A8. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2012.. Clinical and Laboratory Standards Institute. Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic Actinomycetes; Approved Standard--Second Edition. CLSI document M24-A2. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2011.. Clinical and Laboratory Standards Institute. Methods for Antimicrobial Susceptibility Testing for Human Mycoplasmas; Approved Guideline. CLSI document M43-A. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA, 2011.

WARNINGS SECTION.

WARNINGS. Tooth Development The use of drugs of the tetracycline-class during tooth development (last half of pregnancy, infancy and childhood to the age of years) may cause permanent discoloration of the teeth (yellow-gray-brown). This adverse reaction is more common during long-term use of the drugs but it has been observed following repeated short-term courses. Enamel hypoplasia has also been reported. Tetracycline drugs should not be used in this age group, except for anthrax, unless other drugs are not likely to be effective or are contraindicated.Clostridium difficile Associated Diarrhea Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including tetracyclines, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.C. difficile produces toxins and which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial drugs. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.If CDAD is suspected or confirmed, ongoing use of antibacterial drugs not directed against C. difficile need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and institute surgical evaluation clinically indicated.Photosensitivity Photosensitivity manifested by an exaggerated sunburn reaction has been observed in some individuals taking tetracyclines. Advise patients apt to be exposed to direct sunlight or ultraviolet lights that this reaction can occur with tetracycline drugs. Discontinue treatment at the first evidence of skin erythema.Intracranial Hypertension Intracranial hypertension (IH, pseudotumor cerebri) has been associated with the use of tetracyclines including Achromycin V. Clinical manifestations of IH include headache, blurred vision, diplopia, and vision loss; papilledema can be found on fundoscopy. Women of childbearing age who are overweight or have history of IH are at greater risk for developing tetracycline associated IH. Concomitant use of isotretinoin and tetracycline should be avoided because isotretinoin, systemic retinoid, is also known to cause pseudotumor cerebri.Although IH typically resolve after discontinuation of treatment, the possibility for permanent visual loss exists. If visual disturbance occurs during treatment, prompt ophthalmologic evaluation is warranted. Since intracranial pressure can remain elevated for weeks after drug cessation patients should be monitored until they stabilize.Skeletal Development All tetracyclines form stable calcium complex in any bone forming tissue. decrease in fibula growth rate has been observed in premature infants given oral tetracycline in doses of 25 mg/kg every six hours. This reaction was shown to be reversible when the drug was discontinued.Results of animal studies indicate that tetracyclines cross the placenta, are found in fetal tissues and can have toxic effects on the developing fetus (often related to retardation of skeletal development). Evidence of embryotoxicity has also been noted in animals treated early in pregnancy. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to the fetus. Tetracycline drugs should not be used during pregnancy unless absolutely necessary.Antianabolic Action The antianabolic action of the tetracyclines may cause an increase in BUN. While this is not problem in those with normal renal function, in patients with significantly impaired renal function, higher serum levels of tetracycline may lead to azotemia, hyperphosphatemia and acidosis.Laboratory Monitoring for Long-Term Therapy In long-term therapy, perform periodic laboratory evaluation of organ systems, including hematopoietic, renal and hepatic studies. If renal impairment exists, even usual oral or parenteral doses may lead to excessive systemic accumulation of the drug and possible liver toxicity. Under such conditions, lower than usual total doses are indicated, and, if therapy is prolonged, serum level determinations of the drug may be advisable.